{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T07:06:55Z","timestamp":1790233615574,"version":"4.1.0"},"reference-count":50,"publisher":"American Medical Association (AMA)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Paracervical blocks can reduce pain during intrauterine device (IUD) insertions, but the extent and context in which they are used in practice are unclear.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To evaluate paracervical block use during IUD insertions in an academic health system.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This retrospective cross-sectional time-series study was performed at the University of California, San Francisco (UCSF), academic health care system using electronic health record data. Participants included individuals who underwent IUD insertions between July 2, 2012, and August 16, 2024. Data were analyzed from October 2023 to April 2025.<\/jats:p>\n <\/jats:sec>\n \n Exposure<\/jats:title>\n Clinic-, clinician-, and patient-level variables.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Paracervical block receipt was determined from clinical notes. Associations of paracervical block receipt with variables at the clinic, clinician, and patient levels were estimated with multilevel models. The role of clinic specialty (pediatrics or adolescent medicine vs all other specialties) in accounting for the association of age less than 18 years with paracervical block receipt was evaluated using causal mediation analysis.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Among 13\u202f702 IUD insertions (median patient age, 33.16 [IQR, 27.62-37.73] years), 11 713 (85.5%) took place within obstetrics and gynecology (OB-GYN) specialty clinics and almost half (6049 [44.1%]) occurred between a patient-clinician dyad who had never seen each other before. Overall, 5311 insertions (38.8%) included a paracervical block. Paracervical blocks were less frequently used in non\u2013OB-GYN specialties (odds ratio [OR], 0.01; 95% CI, 0.001-0.07) and appointments scheduled for less than 30 minutes (OR, 0.77; 95% CI, 0.66-0.90) and more frequently used when the patient-clinician dyad had a prior visit together (OR, 1.27; 95% CI, 1.09-1.48). A lower proportion of patients aged less than 18 years (84 of 347 [24.2%]) compared with adults (5227 of 135 55 [38.6%]) received a paracervical block, an association mediated by the former population more often receiving care in pediatrics and adolescent medicine clinics (total effect risk difference [RD], \u22120.11 [95% CI, \u22120.19 to \u22120.03]; indirect effect RD, \u22120.22 [95% CI, \u22120.26 to \u22120.18]). Latine patients (OR, 0.77; 95% CI, 0.64-0.94 [reference group, non-Hispanic White patients]) and patients with a preferred language besides English (OR, 0.63; 95% CI, 0.41-0.96) had lower odds of receiving a paracervical block during IUD insertion.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this cross-sectional time series study of IUD insertion procedures in a large academic health system, Latine ethnicity, non-English language preference, no prior patient-clinician visit together, and shorter appointment length were associated with lower odds of receiving paracervical blocks. Potential conduits for increasing paracervical block access include training opportunities, equitable clinic policies, and sufficient appointment duration.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.8406","type":"journal-article","created":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T15:00:18Z","timestamp":1776783618000},"page":"e268406","source":"Crossref","is-referenced-by-count":1,"title":["Use of Paracervical Blocks for Patients Who Undergo Intrauterine Device Insertion"],"prefix":"10.1001","volume":"9","author":[{"given":"Jacquelyn M.","family":"Roger","sequence":"first","affiliation":[{"name":"Biological and Medical Informatics Graduate Program, University of California, San Francisco"},{"name":"Division of Research, Kaiser Permanente Northern California, Pleasanton"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean","family":"Costello","sequence":"additional","affiliation":[{"name":"Department of Environmental Health, Boston University, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Halle","family":"Young","sequence":"additional","affiliation":[{"name":"Medical Anthropology Graduate Program, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thaybeth I.","family":"Malave-Mendez","sequence":"additional","affiliation":[{"name":"Pharmaceutical Sciences and Pharmacogenomics Graduate Program, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brenda Y.","family":"Miao","sequence":"additional","affiliation":[{"name":"Bakar Computational Health Sciences Institute, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claire D.","family":"Brindis","sequence":"additional","affiliation":[{"name":"Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco"},{"name":"Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco"},{"name":"Division of Adolescent and Young Adult Medicine, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen","family":"Meckstroth","sequence":"additional","affiliation":[{"name":"Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryan D.","family":"Hernandez","sequence":"additional","affiliation":[{"name":"Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Whetstone","sequence":"additional","affiliation":[{"name":"Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marissa","family":"Raymond-Flesch","sequence":"additional","affiliation":[{"name":"Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco"},{"name":"Division of Adolescent and Young Adult Medicine, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John A.","family":"Capra","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M. Maria","family":"Glymour","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California, San Francisco"},{"name":"Department of Epidemiology, Boston University, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dara","family":"Torgerson","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,4,21]]},"reference":[{"key":"zoi260265r2","doi-asserted-by":"publisher","first-page":"471","DOI":"10.2147\/IJWH.S213815","article-title":"The efficacy of intrauterine devices for emergency contraception and beyond: a systematic review update.","volume":"11","author":"Goldstuck","year":"2019","journal-title":"Int J Womens Health"},{"issue":"6","key":"zoi260265r3","doi-asserted-by":"publisher","first-page":"772","DOI":"10.1111\/jmwh.13310","article-title":"The intrauterine device experience among transgender and gender-diverse individuals assigned female at birth.","volume":"66","author":"Abern","year":"2021","journal-title":"J Midwifery Womens Health"},{"issue":"1","key":"zoi260265r4","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1097\/AOG.0000000000002390","article-title":"Treatment of low-risk endometrial cancer and complex atypical hyperplasia with the levonorgestrel-releasing intrauterine device.","volume":"131","author":"Pal","year":"2018","journal-title":"Obstet Gynecol"},{"issue":"2","key":"zoi260265r5","doi-asserted-by":"publisher","first-page":"207","DOI":"10.2217\/17455057.3.2.207","article-title":"Levonorgestrel-releasing intrauterine system for the treatment of endometriosis: biological and clinical evidence.","volume":"3","author":"Vigan\u00f2","year":"2007","journal-title":"Womens Health (Lond)"},{"issue":"5","key":"zoi260265r6","doi-asserted-by":"publisher","first-page":"971","DOI":"10.1097\/AOG.0000000000005137","article-title":"Heavy menstrual bleeding treatment with a levonorgestrel 52-mg intrauterine device.","volume":"141","author":"Creinin","year":"2023","journal-title":"Obstet Gynecol"},{"key":"zoi260265r7","doi-asserted-by":"publisher","first-page":"947","DOI":"10.2147\/PPA.S45710","article-title":"Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States.","volume":"8","author":"Yoost","year":"2014","journal-title":"Patient Prefer Adherence"},{"issue":"5S","key":"zoi260265r8","doi-asserted-by":"publisher","first-page":"S2","DOI":"10.1016\/j.jpag.2019.07.001","article-title":"Intrauterine devices: effective contraception with noncontraceptive benefits for adolescents.","volume":"32","author":"Adeyemi-Fowode","year":"2019","journal-title":"J Pediatr Adolesc Gynecol"},{"issue":"4","key":"zoi260265r9","doi-asserted-by":"publisher","first-page":"319","DOI":"10.3109\/13625187.2015.1031885","article-title":"Patients\u2019 experiences and providers\u2019 observations on pain during intrauterine device insertion.","volume":"20","author":"Akintomide","year":"2015","journal-title":"Eur J Contracept Reprod Health Care"},{"issue":"3","key":"zoi260265r10","doi-asserted-by":"publisher","first-page":"163","DOI":"10.1080\/13625187.2023.2189500","article-title":"Assessment of pain and ease of intrauterine device placement according to type of device, parity, and mode of delivery.","volume":"28","author":"Lopes-Garcia","year":"2023","journal-title":"Eur J Contracept Reprod Health Care"},{"key":"zoi260265r11","doi-asserted-by":"publisher","DOI":"10.1016\/j.contraception.2024.110385","article-title":"Factors associated with a negative Patient Acceptable Symptom State (PASS) response with intrauterine device placement: a retrospective survey of HER Salt Lake participants.","volume":"133","author":"Gero","year":"2024","journal-title":"Contraception"},{"issue":"6","key":"zoi260265r13","doi-asserted-by":"publisher","first-page":"615","DOI":"10.1016\/j.jpag.2019.08.004","article-title":"Will it hurt? the intrauterine device insertion experience and long-term acceptability among adolescents and young women.","volume":"32","author":"Callahan","year":"2019","journal-title":"J Pediatr Adolesc Gynecol"},{"issue":"6","key":"zoi260265r14","doi-asserted-by":"publisher","first-page":"556","DOI":"10.1016\/j.contraception.2016.02.007","article-title":"\u201cI don\u2019t know enough to feel comfortable using them:\u201d women\u2019s knowledge of and perceived barriers to long-acting reversible contraceptives on a college campus.","volume":"93","author":"Hall","year":"2016","journal-title":"Contraception"},{"issue":"1","key":"zoi260265r15","doi-asserted-by":"publisher","first-page":"215","DOI":"10.1097\/AOG.0000000000005027","article-title":"TikTok, #IUD, and user experience with intrauterine devices reported on social media.","volume":"141","author":"Wu","year":"2023","journal-title":"Obstet Gynecol"},{"issue":"4","key":"zoi260265r16","doi-asserted-by":"publisher","first-page":"625","DOI":"10.1016\/j.ogc.2013.08.005","article-title":"Pain relief for obstetric and gynecologic ambulatory procedures.","volume":"40","author":"Allen","year":"2013","journal-title":"Obstet Gynecol Clin North Am"},{"issue":"6","key":"zoi260265r17","doi-asserted-by":"publisher","first-page":"704","DOI":"10.1016\/j.contraception.2012.06.004","article-title":"Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block.","volume":"86","author":"Mody","year":"2012","journal-title":"Contraception"},{"issue":"3","key":"zoi260265r18","doi-asserted-by":"publisher","first-page":"263","DOI":"10.5455\/2320-1770.ijrcog20130902","article-title":"Paracervical block with 1% lidocaine for pain control during intrauterine device insertion: a prospective, single-blinded, controlled study.","volume":"2","author":"Cirik","year":"2013","journal-title":"Int J Reprod Contracept Obstet Gynecol"},{"issue":"6","key":"zoi260265r19","doi-asserted-by":"publisher","first-page":"1061","DOI":"10.1111\/jog.13308","article-title":"Lidocaine for pain control during intrauterine device insertion.","volume":"43","author":"Karasu","year":"2017","journal-title":"J Obstet Gynaecol Res"},{"issue":"4","key":"zoi260265r20","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1097\/AOG.0000000000002242","article-title":"Reducing pain during intrauterine device insertion: a randomized controlled trial in adolescents and young women.","volume":"130","author":"Akers","year":"2017","journal-title":"Obstet Gynecol"},{"issue":"11","key":"zoi260265r21","doi-asserted-by":"publisher","first-page":"QC09","DOI":"10.7860\/JCDR\/2017\/25702.10854","article-title":"Paracervical block and paracetamol for pain reduction during IUD insertion: a randomized controlled study.","volume":"11","author":"Dogan","year":"2017","journal-title":"J Clin Diagn Res"},{"issue":"3","key":"zoi260265r22","doi-asserted-by":"publisher","first-page":"575","DOI":"10.1097\/AOG.0000000000002790","article-title":"Paracervical block for intrauterine device placement among nulliparous women: a randomized controlled trial.","volume":"132","author":"Mody","year":"2018","journal-title":"Obstet Gynecol"},{"issue":"1","key":"zoi260265r23","doi-asserted-by":"publisher","first-page":"61","DOI":"10.21608\/ebwhj.2023.246473.1273","article-title":"Efficacy and safety of paracervical block in reducing intrauterine device insertion related pain: a randomized controlled trial.","volume":"14","author":"Khedr","year":"2024","journal-title":"Evid Based Womens Health J"},{"issue":"3","key":"zoi260265r24","doi-asserted-by":"publisher","first-page":"1","DOI":"10.15585\/mmwr.rr7301a1","article-title":"US selected practice recommendations for contraceptive use, 2024.","volume":"73","author":"Curtis","year":"2024","journal-title":"MMWR Morbid Mortal Weekly Rep"},{"issue":"1","key":"zoi260265r26","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0308427","article-title":"National assessment on the frequency of pain medication prescribed for intrauterine device insertion procedures within the Veterans Affairs Health Care System.","volume":"20","author":"Ware","year":"2025","journal-title":"PLoS One"},{"issue":"1","key":"zoi260265r27","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1016\/j.whi.2022.08.002","article-title":"Intrauterine device training, attitudes, and practices among US health care providers: findings from a nationwide survey.","volume":"33","author":"Reeves","year":"2023","journal-title":"Womens Health Issues"},{"issue":"3","key":"zoi260265r28","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.56580","article-title":"Provider Perspectives on analgesic use in intrauterine device insertion procedures: a mixed methods analysis.","volume":"16","author":"Daidone","year":"2024","journal-title":"Cureus"},{"issue":"3","key":"zoi260265r29","doi-asserted-by":"publisher","first-page":"144","DOI":"10.1080\/13625187.2025.2460015","article-title":"Barriers and facilitators for providing pain control during intrauterine device insertion: a multi-center physician survey.","volume":"30","author":"Kirubarajan","year":"2025","journal-title":"Eur J Contracept Reprod Health Care"},{"issue":"6","key":"zoi260265r30","doi-asserted-by":"publisher","first-page":"623.e1","DOI":"10.1016\/j.ajog.2025.07.035","article-title":"Variability in pain management utilization during intrauterine device insertion: a retrospective review.","volume":"233","author":"Landay","year":"2025","journal-title":"Am J Obstet Gynecol"},{"key":"zoi260265r32","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v067.i01","article-title":"Fitting linear mixed-effects models using lme4.","volume":"67","author":"Bates","year":"2015","journal-title":"J Stat Softw"},{"issue":"20","key":"zoi260265r33","doi-asserted-by":"publisher","first-page":"3257","DOI":"10.1002\/sim.7336","article-title":"Intermediate and advanced topics in multilevel logistic regression analysis.","volume":"36","author":"Austin","year":"2017","journal-title":"Stat Med"},{"issue":"4","key":"zoi260265r34","doi-asserted-by":"publisher","first-page":"309","DOI":"10.1037\/a0020761","article-title":"A general approach to causal mediation analysis.","volume":"15","author":"Imai","year":"2010","journal-title":"Psychol Methods"},{"issue":"12","key":"zoi260265r35","doi-asserted-by":"publisher","first-page":"2029","DOI":"10.1001\/jamainternmed.2014.5225","article-title":"Time of day and the decision to prescribe antibiotics.","volume":"174","author":"Linder","year":"2014","journal-title":"JAMA Intern Med"},{"issue":"1","key":"zoi260265r36","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1093\/occmed\/kqs189","article-title":"Changes in nurses\u2019 decision making during a 12-h day shift.","volume":"63","author":"McClelland","year":"2013","journal-title":"Occup Med (Lond)"},{"issue":"9","key":"zoi260265r37","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0257500","article-title":"Time-of-day changes in physician clinical decision making: a retrospective study.","volume":"16","author":"Trinh","year":"2021","journal-title":"PLoS One"},{"issue":"3","key":"zoi260265r38","doi-asserted-by":"publisher","first-page":"214","DOI":"10.1001\/jama.2015.7580","article-title":"Back to the future: volume as a quality metric.","volume":"314","author":"Jha","year":"2015","journal-title":"JAMA"},{"issue":"6","key":"zoi260265r39","doi-asserted-by":"publisher","first-page":"1394","DOI":"10.1016\/j.mayocp.2021.02.030","article-title":"Racism in pain medicine: we can and should do more.","volume":"96","author":"Strand","year":"2021","journal-title":"Mayo Clin Proc"},{"issue":"4","key":"zoi260265r40","doi-asserted-by":"publisher","first-page":"342","DOI":"10.1056\/NEJMsa2034159","article-title":"Racial inequality in prescription opioid receipt\u2014role of individual health systems.","volume":"385","author":"Morden","year":"2021","journal-title":"N Engl J Med"},{"issue":"10","key":"zoi260265r41","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.38070","article-title":"Race and ethnicity and prehospital use of opioid or ketamine analgesia in acute traumatic injury.","volume":"6","author":"Brunson","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"9","key":"zoi260265r42","doi-asserted-by":"publisher","first-page":"1057","DOI":"10.1111\/acem.14550","article-title":"Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference.","volume":"29","author":"Hartford","year":"2022","journal-title":"Acad Emerg Med"},{"issue":"7","key":"zoi260265r43","doi-asserted-by":"publisher","first-page":"1225","DOI":"10.1093\/pm\/pnac057","article-title":"Strategies to promote racial healthcare equity in pain medicine: a call to action.","volume":"23","author":"Telusca","year":"2022","journal-title":"Pain Med"},{"issue":"11","key":"zoi260265r44","doi-asserted-by":"publisher","first-page":"996","DOI":"10.1001\/jamapediatrics.2015.1915","article-title":"Racial disparities in pain management of children with appendicitis in emergency departments.","volume":"169","author":"Goyal","year":"2015","journal-title":"JAMA Pediatr"},{"issue":"1","key":"zoi260265r46","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1186\/s12916-025-03869-7","article-title":"Moments that matter: childhood pain treatment shapes pain for life\u2014we can do better every time in every child.","volume":"23","author":"Slater","year":"2025","journal-title":"BMC Med"},{"issue":"12","key":"zoi260265r47","doi-asserted-by":"publisher","first-page":"12","DOI":"10.3390\/children9121796","article-title":"A qualitative study of the pain experiences of children and their parents at a Canadian children\u2019s hospital.","volume":"9","author":"Kammerer","year":"2022","journal-title":"Children (Basel)"},{"issue":"2","key":"zoi260265r48","doi-asserted-by":"publisher","first-page":"162","DOI":"10.1097\/AJP.0000000000000530","article-title":"The experience of pain dismissal in adolescence.","volume":"34","author":"Defenderfer","year":"2018","journal-title":"Clin J Pain"},{"issue":"1","key":"zoi260265r49","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1007\/s00192-023-05677-0","article-title":"Believing women: a qualitative exploration of provider disbelief and pain dismissal among women with interstitial cystitis\/bladder pain syndrome from the MAPP research network.","volume":"35","author":"Brown","year":"2024","journal-title":"Int Urogynecol J"},{"issue":"3","key":"zoi260265r50","doi-asserted-by":"publisher","first-page":"245.e1","DOI":"10.1016\/j.ajog.2019.09.013","article-title":"Intracervical block for levonorgestrel-releasing intrauterine system placement among nulligravid women: a randomized double-blind controlled trial.","volume":"222","author":"De Nadai","year":"2020","journal-title":"Am J Obstet Gynecol"},{"key":"zoi260265r12","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1007\/978-3-030-17816-1_9","volume-title":"Optimizing IUD Delivery for Adolescents and Young Adults: Counseling, Placement, and Management","author":"Akers","year":"2019"},{"key":"zoi260265r1","unstructured":"Long-acting reversible contraception implants and intrauterine devices. American College of Obstetricians and Gynecologists. November 2017. Accessed September 25, 2024. https:\/\/www.acog.org\/clinical\/clinical-guidance\/practice-bulletin\/articles\/2017\/11\/long-acting-reversible-contraception-implants-and-intrauterine-devices"},{"key":"zoi260265r25","unstructured":"Pain management for in-office uterine and cervical procedures. American College of Obstetricians and Gynecologists. Committee on Clinical Consensus. July 2025. Accessed August 4, 2025. https:\/\/www.acog.org\/clinical\/clinical-guidance\/clinical-consensus\/articles\/2025\/05\/pain-management-for-in-office-uterine-and-cervical-procedures"},{"key":"zoi260265r31","unstructured":"Clinics & locations. UCSF Health. Accessed April 14, 2025. https:\/\/www.ucsfhealth.org\/"},{"key":"zoi260265r45","doi-asserted-by":"crossref","unstructured":"O\u2019Donohue? S. The ripples of trauma caused by severe pain during IUD procedures. The BMJ Opinion. July 20, 2021. Accessed May 5, 2024. https:\/\/blogs.bmj.com\/bmj\/2021\/07\/20\/the-ripples-of-trauma-caused-by-severe-pain-during-iud-procedures\/","DOI":"10.1136\/bmj.n1910"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2847990\/roger_2026_oi_260265_1776190658.52732.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T15:00:20Z","timestamp":1776783620000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2847990"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,21]]},"references-count":50,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,4,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2026.8406","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,21]]}}}